• Conduct retrospective and concurrent audits of claims to verify accuracy of payment, coding, and rate application. • Review claims for proper application of Division of Financial Responsibility (DOFR), benefit matrix interpretation, and regulatory compliance. • Validate application of DRG, APC, ASC, and PPS payment methodologies. • Identify trends and root causes of claim processing errors and recommend corrective actions. • Assist with preparation of audit findings and reports for management review. • Support internal quality control by providing feedback and training recommendations. • Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards. • Maintain knowledge of current CMS, DMHC, and DHS regulations as well as company policies related to claims adjudication. • Participate in special projects, focused audits, or process improvement initiatives as assigned.